病历摘要患者蒋某,男,17岁,住院号81—584。1981年4月22日住院。病史由家属代诉。患者头痛六天,神志不清三天,检查发现眼黄一天。患者于六天前有头晕、头痛、畏寒、发热并伴有全身不适。第二天服民间梨膏糖六块驱虫,次日腹泻一次,未便虫。第三天不慎被狗咬伤右脚跟部,出血少许。第四天起头痛加重,并有呕吐,心窝部及肝区不适,晚呕吐咖啡色液体约150毫升,大便带血,继出现嗜睡,烦躁而进入昏迷状态。当时检查血象增高,肝功能受损,由宜兴转来我院。既往有中耳炎史,否认肝炎及胃病史。检查体温36.5℃,脉搏88次/分,呼吸22次/分,血压120/90毫米汞柱。发育营养中等。呈烦躁昏迷状,检查不合作。巩膜黄染,球结膜水肿,瞳孔等大 Patient summary medical records Jiangmou, male, 17 years old, hospital number 81-584. April 22, 1981 hospitalization. Medical history by family members. Patients with headache for six days, confusion for three days, check the eye yellow day. The patient had dizziness, headache, chills, fever and general malaise six days ago. The next day, civil decontamination sugar pear six deworming, diarrhea the next day, not easy to insects. The third day was bitten by the dog right heel, little bleeding. On the fourth day, my headache aggravated and vomiting, heart and throat and liver discomfort, evening vomit brown liquid about 150 ml, stool bloody, following the emergence of lethargy, irritability and into a coma. At that time check blood increased, impaired liver function, transferred from Yixing hospital. Past history of otitis media, history of hepatitis and stomach denied. Check body temperature 36.5 ℃, pulse 88 beats / min, breathing 22 beats / min, blood pressure 120/90 mm Hg. Medium nutrition. Was fidgety coma, check uncooperative. Sclera yellow dye, conjunctival edema, pupils and other large